Healthcare Provider Details

I. General information

NPI: 1548836984
Provider Name (Legal Business Name): TAWANNA NICOLE JACKSON-SCOTT LCDC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/27/2021
Last Update Date: 05/27/2021
Certification Date: 05/27/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

950 N 4TH ST
LONGVIEW TX
75601-5436
US

IV. Provider business mailing address

107 WOODBINE PL
LONGVIEW TX
75601-2912
US

V. Phone/Fax

Practice location:
  • Phone: 903-757-1106
  • Fax: 903-234-1639
Mailing address:
  • Phone: 903-234-4226
  • Fax: 903-234-1639

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number14037
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: